Treatment of Rare Systemic Autoimmune Rheumatic Diseases (SARDS): Systemic Lupus Erythematous (SLE) and Idiopathic Inflammatory Myopathies - Episode 4
An expert in rheumatic diseases considers therapeutic options for the treatment of SARDS including subcutaneous and intramuscular formulations of Repository Corticotropin Injection as well as immunosuppressive agents.
Kostas N. Botsoglou, MD: Another option for our patients who may be unable to wean down glucocorticoids or continue to have active inflammatory symptoms despite being on steroid-sparing or DMARD [disease-modifying antirheumatic drug] agents, such as mycophenolate, methotrexate, or azathioprine, there’s the option of repository corticotropin, also known as Acthar. Acthar comes in a gel formulation that can be administered subcutaneously or intramuscularly. Typically, these patients have tried and failed or continue to have active symptoms on corticosteroids. The intent of using a repository corticotropin option is to minimize some of the sequelae and long-term adverse effects that chronic steroid use can cause. It’s intended to help decrease disease activity and help maintain a steady state with the patient.
The suggested mechanism of action of repository corticotropin involves the adrenal cortex and the melanocortin system; it shares many features with corticosteroids. However, the majority of its mechanism of action is seen outside the adrenal gland. Thus, it’s suggested to have more of an immunomodulatory effect. Typically, you will see a response as corticosteroids wean off after cessation. Some trials in rheumatoid arthritis demonstrated enhanced or continued activity despite the withdrawal of corticotropin up to 12 weeks after therapy. So, it’s more than a traditional corticosteroid.
I’d prefer to use the subcutaneous route of administration in patients who have good dexterity and have disease activity that requires them to self-administer the treatment. For the intramuscular route, I would reserve that for my patients who might not be as well-versed and may not be able to handle the administration on their own, and thus require a potential caregiver to administer it for them. Alternatively, these are the patients who would come into the office and have it administered by a medical professional.
Patients who are on these medications are on long-term treatment, and we need to monitor them for any adverse effects. Steroids can be used in combination with these medications when patients develop either flare-ups or have severe organ involvement. The selection of these medications is related to what comorbidities or any adverse effects the patients may have had in the past, because they require frequent lab monitoring, such as liver functions, white blood cells, hemoglobin, and platelets. Patients who are on these medications are at increased risk of infections as well, and that needs to be taken into consideration when selecting such agents.
Transcript Edited for Clarity